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Tracking Resistance to Artemisinin (TRAC)

This study is currently recruiting participants. (see Contacts and Locations)
Verified December 2013 by University of Oxford
Sponsor:
Collaborators:
Mahidol University
Worldwide Antimalarial Resistance Network
Information provided by (Responsible Party):
University of Oxford
ClinicalTrials.gov Identifier:
NCT01350856
First received: April 19, 2011
Last updated: December 20, 2013
Last verified: December 2013
  Purpose

Because the artemisinins are the most potent antimalarial drugs, the reduction in parasite numbers is rapid. Therefore, early measures of reducing parasite counts are needed. This study will look at conventional markers of parasite reduction e.g. parasite clearance time, parasite reduction ratio, and the time to achieve a fall of 50%, 90% and 99% of the pre-treatment parasitaemia.

Defining artemisinin resistance requires the use of artesunate (AS) alone because it is now appreciated that the partner drug in a combination treatment has a significant impact on the rate of parasite clearance. This study will dose patients for 3 days with AS alone (or longer until parasites clear) and measure the parasite count frequently in order to be able to define an accurate regression line of a graph of the natural logarithm of the parasite count (Y axis) versus time (X axis). This will be followed by a full course of an artemisinin combination therapy (ACT). Two different dose regimens of artesunate will be compared at all sites except those in western Cambodia, as unpublished observations from the Thai-Myanmar border suggest the standard lower daily dose of 2mg/kg may enable the earlier detection of low level resistance than a 4mg/kg daily dose.


Condition Intervention Phase
Falciparum Malaria
Drug: Artesunate 2
Drug: Artesunate 4
Phase 4

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
Official Title: A Multicentre, Randomised Trial to Detect in Vivo Resistance of Plasmodium Falciparum to Artesunate in Patients With Uncomplicated Malaria.

Resource links provided by NLM:


Further study details as provided by University of Oxford:

Primary Outcome Measures:
  • Parasite clearance rate [ Time Frame: Day 42 ] [ Designated as safety issue: No ]
    Defined by the slope of the linear portion of the natural logarithm parasite clearance curve.


Secondary Outcome Measures:
  • Parasite clearance time [ Time Frame: Day 42 ] [ Designated as safety issue: No ]
    Assessed by microscopy

  • Parasite reduction rates and ratios [ Time Frame: Day 42 ] [ Designated as safety issue: No ]
    Assessed by microscopy and quantitative PCR.

  • Time for parasite count to fall [ Time Frame: 50%, 90%, and 99% ] [ Designated as safety issue: No ]
    Time for parasite count to fall to 50%, 90%, and 99% of initial parasite density

  • Fever clearance time [ Time Frame: > 24 hours ] [ Designated as safety issue: No ]
    The time taken for tympanic temperature to fall below 37˚C and remain there for at least 24 hours

  • Gametocytemia in patients [ Time Frame: days 0, 3, 7 and 14 ] [ Designated as safety issue: No ]
    Proportion of patients with gametocytemia before, during and after treatment with artesunate, assessed at admission, on days 3, 7 and 14, stratified by presence of gametocytes at enrolment

  • Gametocyte carriage rates [ Time Frame: 14 days ] [ Designated as safety issue: No ]
  • In vitro susceptibility of P.falciparum to artemisinins [ Time Frame: Day 42 ] [ Designated as safety issue: No ]
    Measure the inhibitory concentrations (IC) 50, IC90, IC99 of P. falciparum responses to artemisinins ex vivo

  • Pharmacokinetics relationships for artesunate and Dihydroartemisinin (DHA) [ Time Frame: Day 42 ] [ Designated as safety issue: No ]
    Measure half-life, Cmax, AUC, Tmax of artesunate and DHA.

  • Parasite molecular markers of drug resistance [ Time Frame: Day 42 ] [ Designated as safety issue: No ]
    To identify the parasite specific molecular marker which is correlated to artemisinin resistance

  • Identification of host factors that correlate with slow parasite clearance [ Time Frame: Day 42 ] [ Designated as safety issue: No ]
    To identify host factors influencing the clearance of P. falciparum, e.g. haemoglobinopathies and G6PD deficiency

  • Efficacy at D42 [ Time Frame: Day 42 ] [ Designated as safety issue: No ]
    The cure rate of artesunate plus ACT treatments at 42 day of follow up.

  • Pharmacodynamics relationships for artesunate and Dihydroartemisinin (DHA) [ Time Frame: Day 42 ] [ Designated as safety issue: No ]

Estimated Enrollment: 1800
Study Start Date: May 2011
Estimated Study Completion Date: April 2014
Estimated Primary Completion Date: April 2014 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Active Comparator: Artesunate 2
Artesunate 2 mg/kg/day for 3 days followed by a full course of either artemether-lumefantrine or DHA-piperaquine or artesunate-mefloquine or artesunate-amodiaquine
Drug: Artesunate 2
Artesunate 2 mg/kg/day for 3 days followed by a full course of either artemether-lumefantrine or DHA-piperaquine or artesunate-mefloquine or artesunate-amodiaquine
Experimental: Artesunate 4
Artesunate 4 mg/kg/day for 3 days followed by a full course of either artemether-lumefantrine or DHA-piperaquine or artesunate-mefloquine or artesunate-amodiaquine
Drug: Artesunate 4
Artesunate 4 mg/kg/day for 3 days followed by a full course of either artemether-lumefantrine or DHA-piperaquine or artesunate-mefloquine or artesunate-amodiaquine

Detailed Description:

Background:

Artemisinins are the cornerstone of current antimalarial treatment. Evidence of reduced susceptibility to artemisinins in Western Cambodia was first presented in January 2007 and confirmed in a subsequent detailed pharmacokinetic-pharmacodynamic study conducted by our group. Artemisinin resistance was manifest by a marked slowing of parasite clearance. The spread of highly artemisinin resistant falciparum malaria would have devastating consequences for malaria control and elimination. The response to artemisinin resistance in P. falciparum depends critically upon answering one pivotal question: how far has it spread? This research proposal focuses on filling critical gaps in knowledge that are essential to planning an effective response.

Objectives/Hypothesis/Questions:

This is a multi-centre study with the primary objective of comparing the P. falciparum parasite clearance compared to a reference parasite clearance rate obtained from historical data in artemisinin sensitive falciparum malaria.

The aim of this large scale study is to determine if artemisinin resistance has spread and if so, how far it has spread.

Research design:

This is a multi-centre, open-label randomised trial to assess the clearance rates of peripheral blood P. falciparum parasitaemias in patients with acute uncomplicated falciparum malaria treated with two different doses of artesunate.

The study will recruit patients with acute uncomplicated P. falciparum malaria. The total number of patients for this study is expected to be 1800.

Patients will be randomised 1:1 to receive either:

  • AS2: Artesunate 2 mg/kg/day for 3 days OR
  • AS4: Artesunate 4 mg/kg/day for 3 days
  • followed by a full course of Artesunate- mefloquine (MAS3) Patients will be hospitalised for at least the 1st three days. During hospitalisation, patients will have malaria parasite count done at 0, 4, 6, 8, 12, then every 6 hours until parasite clearance. The weekly follow up is until day 14 (on Day 7 and Day 14).

Value and significance of the research The study aims to address a simple but crucial question regarding artemisinin resistance for which currently there is no answer: has artemisinin resistant Plasmodium falciparum spread from Western Cambodia? The results will determine how to approach the subsequent efforts; strengthening of strategies for eliminating the resistant parasites in Western Cambodia if the resistance is confined to this area, or for containment and malaria control if the resistant parasites have already spread.

Potential outcomes Within one year we expect to produce a map of the geographical extent, prevalence and severity of artemisinin resistance.

  Eligibility

Ages Eligible for Study:   6 Months to 65 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Male or female, aged from 6 months to 65 years old, inclusive
  • Acute uncomplicated P. falciparum malaria, confirmed by positive blood smear with asexual forms of P. falciparum (or mixed with non-falciparum species)
  • Asexual P. falciparum parasitaemia: 10,000 to 200,000/uL, determined on a thin or thick blood film
  • Fever defined as > 37.5°C tympanic temperature or a history of fever within the last 24 hours
  • Written informed consent (by legally acceptable representative in case of children)
  • Willingness and ability of the patients/guardians to comply with the study protocol for the duration of the study

Exclusion Criteria:

  • Signs of severe/complicated malaria (WHO, 2000)
  • Haematocrit < 25% or haemoglobin (Hb) < 8 g/dL at enrollment
  • Acute illness other than malaria requiring treatment
  • For females: pregnancy, breast feeding
  • Patients who have received artemisinin or a derivative or an artemisinin-containing combination therapy (ACT) within the previous 7 days
  • History of allergy or known contraindication to artemisinins, or to the ACT to be used at the site
  • Previous splenectomy
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01350856

Contacts
Contact: Nicholas J White, DSc MD +662-203-6301 nickw@tropmedres.ac
Contact: Elizabeth Ashley, MB BS PhD liz@tropmedres.ac

Locations
Bangladesh
Ramu Upazila Health Complex Terminated
Cox's Bazaar, Bangladesh
Cambodia
Pailin General Hospital Completed
Pailin, Cambodia
District Referral Hospital Completed
Preah Vihear, Cambodia
Pursat Referral Hospital Completed
Pursat, Cambodia
District Referral Hospital Completed
Rattanakiri, Cambodia
Congo, The Democratic Republic of the
Kingasani Health Centre Completed
Kinshasa, Congo, The Democratic Republic of the
India
Sulkapara Block Primary Health Center Terminated
West Bengal, India
Kenya
Pingilikani Dispensary Completed
Kilifi, Kenya
Lao People's Democratic Republic
Phouvong District Hospital Not yet recruiting
Phouvong, Attapeu, Lao People's Democratic Republic
Contact: Mayfong Mayxay, MD       mayfong@tropmedres.ac   
Principal Investigator: Mayfong Mayxay, MD         
Myanmar
Myitkyina Recruiting
Myitkyina, Kachin, Myanmar
Contact: Kyaw Myo Tun, MD       myo.kyaw.tun@gmail.com   
Principal Investigator: Frank Smithuis, MD         
Sub-Investigator: Kyaw Myo Tun, MD         
Day Bu Noh Recruiting
Luthaw, Karen, Myanmar
Contact: Craig Bonnington, PhD       c.a.bonnington@gmail.com   
Principal Investigator: Francois Nosten, MD         
Sub-Investigator: Craig Bonnington, PhD         
Pyin Oo Lwin Recruiting
Mandalay, Mandalay Region, Myanmar
Contact: Khin Lin, MD       dr.khinlin.dir@gmail.com   
Principal Investigator: Khin Lin, MD         
Thabeikkyin Hospital Recruiting
Thabeikkyin, Mandalay, Myanmar
Contact: Kyaw Myo Tun, MD       myo.kyaw.tun@gmail.com   
Principal Investigator: Frank Smithuis, MD PhD         
Shwe Kyin Hospital Terminated
Shwe Kyin, Myanmar
Nigeria
University of Ilorin Teaching Hospital Terminated
Ilorin, Nigeria
Thailand
Shoklo Malaria Research Unit Completed
Mae Sot, Tak, Thailand
Kraburi Hospital Terminated
Ranong, Thailand
Phusing Hospital Terminated
Srisaket, Thailand
Vietnam
Phuoc Long Hospital Completed
Binh Phuoc, Vietnam
Sponsors and Collaborators
University of Oxford
Mahidol University
Worldwide Antimalarial Resistance Network
Investigators
Principal Investigator: Nicholas J White, DSc MD Mahidol Oxford Research Unit
  More Information

No publications provided by University of Oxford

Additional publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
Responsible Party: University of Oxford
ClinicalTrials.gov Identifier: NCT01350856     History of Changes
Other Study ID Numbers: BAKMAL1101
Study First Received: April 19, 2011
Last Updated: December 20, 2013
Health Authority: United Kingdom: Research Ethics Committee

Keywords provided by University of Oxford:
Uncomplicated P. falciparum malaria

Additional relevant MeSH terms:
Malaria
Malaria, Falciparum
Parasitic Diseases
Protozoan Infections
Artemether-lumefantrine combination
Artemisinins
Artesunate
Lumefantrine
Piperaquine
Amebicides
Anti-Infective Agents
Antimalarials
Antiparasitic Agents
Antiprotozoal Agents
Pharmacologic Actions
Therapeutic Uses

ClinicalTrials.gov processed this record on November 27, 2014